Va Form 21-526b - Veteran'S Supplemental Claim For Compensation

Download a blank fillable Va Form 21-526b - Veteran'S Supplemental Claim For Compensation in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-526b - Veteran'S Supplemental Claim For Compensation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

OMB Control No. 2900-0001

Respondent Burden: 15 minutes

VA DATE STAMP

DO NOT WRITE IN THIS SPACE

VETERAN'S SUPPLEMENTAL CLAIM FOR COMPENSATION

IMPORTANT: PLEASE READ THE PRIVACY ACT NOTICE AND RESPONDENT BURDEN INFORMATION

BELOW BEFORE COMPLETING THIS FORM.

PART I - VETERAN'S IDENTIFYING INFORMATION

1. NAME OF VETERAN (First, Middle, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S ADDRESS (Number, street or rural route, City or P.O., State and ZIP Code)

6. E-MAIL ADDRESS (If applicable)

5. TELEPHONE NUMBER(S)

A. DAYTIME (Include Area Code)

B. EVENING (Include Area Code)

PART II - INFORMATION ABOUT CLAIM

7. I WOULD LIKE TO FILE A CLAIM FOR: (Check all that apply)

INCREASED EVALUATION OF THE DISABILITY(IES) FOR WHICH I AM ALREADY SERVICE CONNECTED

(Provide the name of the disability(ies))

SERVICE CONNECTION FOR NEW DISABILITY(IES) (List your new disability(ies))

REOPENING OF PREVIOUSLY DENIED DISABILITY(IES) (List your previously denied disability(ies))

DISABILITY(IES) SECONDARY TO MY EXISTING SERVICE CONNECTED DISABILITY(IES)

(Provide the name of the disability(ies) and your service connected condition(s))

8A. NAME AND LOCATION OF VA MEDICAL CENTER THAT HAS MY

8B. NAME AND ADDRESS OF MILITARY FACILITY THAT HAS MY RELEVANT

RELEVANT TREATMENT RECORDS

TREATMENT RECORDS

8C. DO YOU HAVE PRIVATE TREATMENT RECORDS?

(If "Yes," please attach the treatment records to this form. If you would like to have VA request your private treatment records, please attach a

VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, for each private treatment provider.

YES

The form is available at )

9. I WOULD LIKE TO FILE A CLAIM FOR OTHER VA BENEFITS (Check appropriate box)

OTHER (Specify benefit)

AID AND ATTENDANCE

AUTOMOBILE ALLOWANCE

10. I WOULD LIKE TO FILE A CLAIM FOR ADDITIONAL BENEFITS

A. SPOUSE'S NAME

B. SPOUSE'S SOCIAL SECURITY NO.

BECAUSE MY SPOUSE IS SERIOUSLY DISABLED

(Please provide spouse's name and social security number in

Items 10A & 10B)

11A. VETERAN'S SIGNATURE (Do NOT print)

11B. DATE SIGNED

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal

Regulations 1.576 for routine uses (i.e. civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in

which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA

system of records, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is

required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). The VA will not deny an individual

benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is

considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information that you furnish may be utilized in

computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue

of your participation in any benefit program administered by the Department of Veterans Affairs.

RESPONDENT BURDEN: We need this information to make an eligibility determination for veterans' filing supplemental compensation claims (38 U.S.C. 5101). Title 38, United States Code, allows us to

ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of

information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the

OMB Internet Page at If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM

SUPERSEDES VA FORM 21-526B, JUL 2009,

21- 526b

MAY 2010

WHICH WILL NOT BE USED.